War Psychiatry, Chapter 5, Alcohold and Drug Abuse and Dependence

Alcohol and Drug Abuse and Dependence Chapter 5 ALCOHOL AND DRUG ABUSE AND DEPENDENCE HENRY K. WATANABE, M.D.,* PAUL T. HARIG, PH.D.,† NICHOLAS L. ROCK, M.D.,‡ AND RONALD J. KOSHES, M.D.§ INTRODUCTION HISTORY DIAGNOSIS AND DEFINITIONS DETERMINANTS OF SUBSTANCE ABUSE CURRENT THEORIES IDENTIFICATION TREATMENT MANAGEMENT OF CLINICAL CONDITIONS TREATMENT MODALITIES PREVENTION AND CONTROL OPERATIONAL CONSIDERATIONS SUMMARY AND CONCLUSION *Colonel, Medical Corps, U.S. Army; Medical Member Physical Evaluation Board, Walter Reed Army Medical Center; Guest Scientist, Department of Military Psychiatry, Walter Reed Army Institute of Research, Washington, D.C. 20307–5100 †Lieutenant Colonel, Medical Service Corps, U.S. Army; Director, Army Fitness Research Institute, Army War College, Carlisle Barracks, Pennsylvania 17013–5050 ‡Colonel (ret), Medical Corps, U.S. Army; Medical Director, The Rock Creek Foundation, Silver Spring, Maryland 20910–4457 §Medical Director, Adult Services Administration, Commission on Mental Health Services, Department of Human Services, District of Columbia, Washington; Guest Scientist, Department of Military Psychiatry, Walter Reed Army Institute of Research, Washington, D.C.; Assistant Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland; President, Society of American Military Psychiatrists 61 Military Psychiatry: Preparing in Peace for War INTRODUCTION Among the numerous studies1,2,3 that have at- reported to have doubled every year from 1967 to tempted to explain why some occupational groups 1969.5 The return from Vietnam of thousands of claim a higher level of excessive alcohol consump- soldiers who had reportedly used heroin raised tion, the common threads of stress and boredom are public anxiety over the possibility of a drug epi- found. It is not surprising that alcohol and sub- demic, and a congressional investigation confirmed stance abuse could become problems in a combat that overseas drug use was prevalent among U.S. environment because they are expedient pathways troops.4 Indeed, the Vietnam conflict was the first to stress management. American war in which drug and alcohol depen- The history of past wars demonstrates this. In the dency overshadowed combat stress reactions as a late 1960s and early 1970s, thousands of returning problem for military psychiatry. The large preva- soliers who had served in Vietnam and reportedly lence of drug abuse among troops in Vietnam had used narcotics there aroused public anxiety about unique political sensitivity for an administration the existence of a drug epidemic among U.S.troops.4 that had campaigned on a strong law and order Before the early 1970s, the military dealt with platform that tied drug use to rising crime rates. It serious substance abuse by administrative and le- also added fuel to opponents’ demands for immedi- gal means (discharge and punishment) although it ate troop withdrawals, which, in turn, was per- did not respond to every instance of substance ceived as a major political threat to the President’s abuse. The medical concerns were with treating Vietnamization program.6 serious medical complications. However, after 1970, In response, the administration created a drug Congress mandated a change from punitive mea- abuse office within the Federal Government, em- sures to treatment and rehabilitation. Since then, phasizing the prevention of drug abuse through improvements have resulted in providing a com- education and law-enforcement procedures focus- prehensive program based on command responsi- ing on detection. The day after the President de- bility with significant medical interface. Currently, clared a national counteroffensive against drug the basic policy in the military services is to keep a abuse, the U.S. Army in Vietnam began urine test- sustained effort to prevent substance abuse prob- ing for opiates for all soldiers completing their lems from occurring and to eliminate from the ser- tours. Detoxification, treatment, and rehabilitation vice those who cannot effectively be restored within were provided to those who were identified as a reasonable period. heroin abusers. Army regulations were soon modi- Substance abuse is not tolerated not only because fied to create an amnesty for those who voluntarily of its physiological effects on the abuser that would turned themselves in for treatment. This amnesty jeopardize mission requirements, but also because was a big step because it eliminated criminal conse- of its psychosocial implications in the unit. While a quences to treating individuals for problems with kind of cohesion can occur around the use of sub- narcotics. By November 1971, unannounced testing stances,1 substance abuse is definitely damaging to for amphetamines and barbiturates, as well as opiates, the good order and morale of the unit and interferes had commenced worldwide, and treatment programs with mission accomplishment. were being phased in throughout the world.7 The command structure has been charged with Recently, the epidemic of crack and cocaine use the responsibility for the alcohol and drug abuse in the civilian population has had parallel conse- program. The medical services are to offer consulta- quences in the military. Given the generally poor tion and technical supervision to individuals who rate of rehabilitation for these substances using work for the command and to provide specific and conventional treatments, the appearance of cocaine direct medical support for those with identified and crack on the military scene has resulted in problems. The purpose of this chapter is to assist significant manpower losses. Koshes and Shanahan8 medical personnel to achieve those command goals tracked the disposition of soldiers who tested posi- and objectives. tive for cocaine at a U.S. Army training post. All of The illegal use of drugs in civilian life and in the those who tested positive were dismissed from the military began to steadily increase after 1967, and service, many of whom were high-ranking enlisted illicit drug usage among military personnel was soldiers with many years of service. 62 Alcohol and Drug Abuse and Dependence HISTORY Pre-1971 During the Russo-Japanese War (1904–1906), the Russians identified three common types of Alcohol problems have existed in most of the “mental cases”: depressive syndrome, general armies throughout the world since historical records paresis, and alcohol psychosis.12 In the U.S. have been kept. Narcotic addiction occurred during Army, from 1907–1917, admissions for alcohol the Civil War, World War I, World War II, the problems were 16 per 1,000 troops per annum.13 Korean conflict, and the Vietnam conflict, as well as During World War II, the alcohol admission with soldiers stationed in the continental United rate was 1.7 per 1,000 troops per annum, while States and overseas between and after the conflicts. the drug addiction rate was 0.1 per 1,000 Substance abuse has always been a potential occu- troops per annum. Combined, they made up pational hazard for medical personnel. As Farley 4.7% of all psychiatric diagnosis.14 Since World has observed, “Addiction to mood altering chemi- War II and until 1970, the pattern had remained cals ... is also a major problem in the medical profes- the same. However, in the 1970s drug abuse sion and particularly in the specialty of anesthesia.”9(p1) problems increased significantly in the armed This is in part because anesthesiologists have legal forces.2 (although controlled) access, in part because of the Attempts at solving the problems have been high stress and responsibilities of the profession, and historically poor. The Federal Anti-Narcotic Act in part because of a tendency for educated medical in 1914, the infamous prohibition act of 1919 to professionals to rationalize that they can self-admin- 1933, and the Federal Addiction Rehabilitation ister dangerous and addictive drugs safely. Act of 1966 were national attempts focusing The highly addictive properties of controlled mostly on the civilian community. medical substances such as the anesthetic fentanyl10 create unique problems for medical providers. The Post-1971 temptations of access and the dangers of self-administration of these drugs by military medical The subject of alcohol rehabilitation deserves personnel was evidenced in a near-epidemic of fen- special attention in this chapter because alcohol tanyl abuse among tri-service anesthesiologists and problems have traditionally been handled some- nurse anesthetists in the early 1980s. This abuse led what apart from other drugs of abuse, yet treat- to the special rehabilitation program for military ment policies were closely influenced by the personnel that is dictated by a quality assurance Department of Defense (DoD) drug counterof- regulation.11 This regulation linked substance abuse fensive. Initially, the recognition of the occupa- rehabilitation and medical quality assurance. The tional significance of alcoholism and support purposes were to ensure that during rehabilitation, for its treatment was stimulated by several con- the practice credentials of drug-dependent health gressional initiatives, including the passage of professionals were restricted, and that their recov- important enabling legislation and the estab- ery was carefully monitored by medical authorities. lishment of the National Institute on Alcohol These policies reflected impaired health provider Abuse and Alcoholism to coordinate research statutes that were enacted by the state regulatory

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